Another Black tongue

Dear Colleagues,

I would like to post this case of black tongue and inner lips of this young lady who fixed a metal bridge of silver one month before the appearance of this pigmentation on the inner lips (note the exact match of the bridge and the site of pigment , the presence of pigment on tongue because the patient tongue comes in contact with bridge.

(first three pic are clnical then perl stain, left and below(negatvie) fontana masson middle and below (positive) then H+E  right and below)

I performed for her 3 mm punch biopsy and sutures with silk 5/0, the biopsy showed pigment in the dermis with many melanophges, there was no increase pigment in the basal cell layer, so genetic melanosis was ruled out, there was no inflammotory cells so drug eruption and contact and lichen planus were ruled out. Fontana Massson stain was positive though it is not specific for silver because it stains also melanin, but it was positive.

I send this case to agree with my colleague Dermlive that shisha tip if it was made of metal will cause this pigmentation which is practically a form of a tattoo, treatment is difficult and depends on the ability of the melanophages to scavenge abd clean the lamina properia from this silver deposition.

 A careful history of contact with metals (bridges, metal tip of sheesha ) should always be asked about in a black tongue and skin biopsy is mandatory in this.

Best Regards

POLL: Can potent steroids cause atrophy in vitliginous patches?

it has been reported anectodally that vitliginous patches is resistant to steroid’s complications.
have you seen any cases of vitiligo complicated with atrophy due to potent topical steroids?

Do you have a name for it?

are these fordyce spots?
and how would you treat it?
i thought about electrocautery but am afraid of scarring especially in this area.
what would you do?

black tongue

 

 2o year old man with pigmented spots over his tongue for 6 months. He smokes sheesha occasionally. He denies any bad smell.

On examination he has multiple pigmented patched over the sides of his toungue. other parts of his oral mocosa are intact. No ulcers

Could this be a hairy tongue?

But the dorsum of the tongue is not involved and only subtle hypertropthy of the filiform paillae.

 

Other DDX

Oral Candidiasis

Venous lake? (looks bluesih)

 

Any thoughts appreciated

Erythema dyschromicum perstans (Ashy dermatosis)

 Dear colleagues, I would like to present this case of Erythema dyschromicum perstans to contiue our valuable discussion for the case “A lady with a violaceous lesions”.

This patient is a 35 year old Saudi lady that has a gray-blue ill defined discoloration on neck, face and proximal arms for 7 years. These lesions are preceded by itch erythema.The patient received many ways of treatments including topical hydroquinones, Kligman formula and others.She came to the dermatology clinic for Laser or chemical peel treatment.

4 mm punch Skin biopsy from Rt submental area(hidden area) was done (Blue Nylon sutures can be seen  in the photo) was done.Histology showed normal basket weaven stratum corneum, focal interface with exocytosis of lymphocytes within the epidermis, no band like lymphocytic infiltrate but dense perivascular melanophges (the deep deposition of melanin gives this blue-gray hue according to Tendal’s phenomenon).No eosinophils were seen(drug eruption was ruled out and the patient is on no medication from the clinical history) .These pathological findings are typical for erythema dyschromicum perstans.This disease is differentiated from Lichen planus by the normal basket weaven stratum corneum, the abscence if lichenoid lymphocytic infiltrate and colloidal bodies and the abscence of focal hypergranulosis and saw teeth rete ridges.

 

I started her on topical and systemic steroids for 1 month, the itching and erythema(new lesions developing at forearms-not shown-) cleared completely but the dyspigmentation persisted, topical steroids were continued for another 2 months but the patient did not show up again.

I choosed to give her topical steroids to seal the basement membrane which is the source of the pigment incontinence , obviously peeling will not work, hydroquinon could be given to slow down the formation of new melanin, Q-SWITHCHED laser role in this case is not effective because this is an inflammatory disease and the pigment will come back or even get worse.

what I would like to emphasize in this case that skin biopsy should be done for any suspicious case of erythema dyschromicum and no laser trial to be done for non responding inflammatory dermatosis.

dermatology residancy is five years!

according to one of the residants, there is serios talk about extending the residancy to 5 years from its current duration(4 yrs, one year of general and 3 years core).

they say that four years were not enough to teach the reidants all aspects of clinical dermatology and dermatological surgery. the society itslf  has changed its name from saudi society of dermatology to dermatology and dermatological surgery.

there are simillar programs with 5 years of  residancy (canada) and even more (australia, uk up to 7).

others think that the four years is more than enough for a dermatologist to be ready to start practicing.

whatever it happens, this will probably do little to the huge number of applicants (more than 100)

that apply each year for 7-8 spots each year in riyadh alone.

what do you think of the local brand of topical steroids?

hey guys,

i have been using theses local creams (ELICA) manufactures here or in nieboring countries. and patients just swear they not getting the same results like with ELOCOM , is it just my patients or are you haveing the same problem.

 what about other treatments? i herd there is indian roacutane …they complain about that too?and hairgrow, do u stress on buying orginal products or go for the cheaper or the one availavle in gov hospital?

thanks

treatmnet of alopecial in pregnancy

Dr SAMIR wrote

i have a question
a case of alopesia areata,multiple lesions on scalp in a lady 22 years old pregnant one month.can i inject inralesional corticosterid? can i prescribe minoxidil topical? i need ur advice

woods light for vitiligo? r u doing it

woods light has many applications in dermatology. from common diseases such as fungal infetions to rare diseases (porphria) it has been used for long time.

but the  most common application for it in darker skin tyes is problably in hypo/dpigmented disorders. however me and my fellow dermatologists rarely use it. there is no doupt that it is of great value in white skin where its extremly difficult to discern the patch or even grade its color. but in darker skin, the lesion is usully obvious clinicaly. those which look hypopigmented (or if you not sure) dont enhance. wheras these lesions whick are realy white and they will enhance chalky white.

pateints always like this mysterious blue sophisticated light, but is it worth doing?

who is doing it? did it ever change ur clinical guess?

lets vote!

( :

whats eating her flesh?

25 years old female who has been having lesion for 4 years. it started on her left arm and nose. it is always painful and and end up in wonds that takes months to heal. her nose was destroyed and she had to have reconstructive surgery. she was on various medication including high dose predinsolone, Immuran whis she improved on but she  always had a relapse. apart from arthrlagia her systemic inquirey was insignificant

on examination: she had larger ulcers on both of her arms with blisters and scarring sorrounding active lesions. the active lesions has an erythematous rim sorrounding it.

Lab:

Hgb: 10.1       wbc: 7       Plt: 220         ESR: 120         ANA :1280      Antids:1400

currently she is admitted for iv methy pred (shifted to oral predinsolone 70 mg) and she undergoing more investigation. the biopsy was taken we are wating for the results.

Reason for submitiing case: we thought of pyoderma gangrenosum (bollous ) but the serology was pointing toards lupus. we also are considering vasculitis

any other thoughts?